One Health Lewisham: Lewisham GP 3TT pilot

One Health Lewisham and Lewisham Clinical Commissioning Group worked together with GP practices to increase the proportion of diabetic patients meeting the key three treatment targets for blood pressure, cholesterol and blood glucose levels. Patients meeting these have increased from 42 per cent to 46.7 per cent. More patients are also receiving more of their care at their local practices rather than having to travel.

This was achieved through helping practices to identify patients who would benefit from interventions, standardising systems to recall patients and processes in their management, and getting GPs working together in larger groups with a shared vision around better diabetic care. A diabetes facilitator undertook practice visits and support, and cross organisation multidisciplinary teams and networks focused on effective clinical management. Other organisations such as the local trusts and community-based services were drawn into transformation meetings. Lead GPs, practice managers and administrators were offered training, and practices got individualised performance dashboards.

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